Complex Claims Clinical Reviewer

Job not on LinkedIn

🕒 April 30

🐊 Florida, North Carolina, +4 more states – Remote

🐊 Florida – Remote 🌲 North Carolina – Remote 🦀 Maryland – Remote 🌴 South Carolina – Remote 🎸 Tennessee – Remote ⚔️ Virginia – Remote

💵 $68k - $88.4k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔍🏥 Medical Reviewer

👻 Ghost score 25%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Vaya Health

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 1972

🛡️ Insurance

💼 Consulting

📦 Logistics

Insurance • Consulting • Logistics

Vaya Health is a North Carolina-based organization that manages services for individuals with behavioral health issues, including mental health and substance use disorders, intellectual and developmental disabilities (I/DD), and traumatic brain injuries (TBI). The organization provides Medicaid services tailored for these populations, focusing on a person-centered approach that connects members to the necessary care and support for their unique health and wellness goals. Vaya Health emphasizes collaboration across various care areas to ensure comprehensive support for its members, fostering healthier communities across the region.

📋 Description

• Conduct prepayment and post-payment audits and reviews of complex inpatient hospital claims • Audit inpatient medical records and clinical documentation to evaluate coding and MS-DRG assignment accuracy • Validate billed ICD-10-CM and ICD-10-PCS codes and MS-DRGs • Apply clinical expertise, evidence-based criteria, medical policy, medical necessity guidelines, and accepted standards of care • Generate Decision Action Notices with clear rationales referencing clinical evidence • Initiate and verify claim adjustments • Maintain audit documentation and prepare statistical data • Identify, monitor, and analyze aberrant utilization patterns and potential provider fraud • Complete claims queries for high-dollar and complex-care criteria • Participate in informal and formal appeals and defend decisions before reconsideration panels, hearing officers, and administrative law judges • Provide litigation testimony as applicable • Work with regulatory bodies on fraud prevention and compliance • Propose fraud-prevention edits for automated claims and billing systems • Provide technical assistance and provider education as needed • Perform other duties as assigned

🎯 Requirements

• Bachelor's degree in nursing with an active license or bachelor's degree in health information management • 5 to 7+ years of experience working with ICD-10 and MS-DRG • Broad knowledge of medical claims payment systems, provider billing guidelines, payer reimbursement policies, medical necessity criteria, and coding terminology • Active and unrestricted RN license in North Carolina or Nurse Licensure Compact (NLC) license required for nursing degree pathway • Expert knowledge of DRG and ICD-10 coding • Knowledge of official coding guidelines, Coding Clinic determinations, CMS, and other regulatory compliance guidelines and mandates • Strong working knowledge of applicable industry-based standards • Proficiency in Word, Access, Excel, and other applications • Excellent written and verbal communication skills • Medicaid experience is a plus • Inpatient Coding Credential (CCS) preferred • Must live in NC, SC, GA, TN, VA, MD, or FL • Ability to perform sedentary work, sit for extended periods, and lift up to 10 pounds • Close visual acuity and ability to perform extensive reading and repetitive hand, wrist, and finger motions

🏖️ Benefits

• Remote, home-based virtual position • Monday–Friday schedule, 8:30am–5:00pm EST • Exempt position not eligible for overtime compensation